Children and Youth with Special Health Care Needs Program Provider Manual

CYSHCN billing guidelines must be followed in order for services to be considered for payment. Billing guidelines include but are not limited to:

• Participant must be actively enrolled in the CYSHCN Program on the date of service.
• Provider must be an enrolled SHCN provider on the date of service.
• CYSHCN must receive provider claims within 90 calendar days of the date of service or within 90 calendar days of the Explanation of Benefits (EOB)/Remittance Advice (RA) process date but no longer than 6 months from the date of service.
• CYSHCN will only reimburse up to the amount of the participant’s/family’s responsibility.
• Participants/families will not be billed for approved CYSHCN services.
• Some services require prior authorization which must be obtained before the delivery of services.
• Services must be medically necessary and directly related to the participant’s CYSHCN eligible diagnosis.
• CYSHCN will consider limited funding up to $25,000 annually per participant.
• Participants with private insurance or MO HealthNet must utilize in-network providers.
• CYSHCN is the payor of last resort.
• Hearing aid claims must be accompanied by the invoice.
• Claims must be billed to CYSHCN (not the participant/family or other third party payers).
• The claim should list the Usual and Customary Rate (UCR), not the prior authorized amount.
  • UCR is the individual provider’s standard charge to the general public for the service, supply or equipment.
• Claims must include a valid CPT, HCPCS, NDC, or CDT code.

Additional Provider Responsibilities

• CYSHCN Program participants are issued an eligibility letter and are instructed to present this letter to providers before the provision of service. It is the provider’s responsibility to obtain a copy of this eligibility letter.
• The provider is encouraged to consult with the participant's Service Coordinator to verify participant eligibility and to obtain a prior authorization for services when required. The Service Coordinator’s contact information is listed on the participant’s eligibility letter.
• It is the responsibility of the provider to obtain prior authorization of services from CYSHCN. Neither CYSHCN nor the participant/family will be responsible for payment of a service when the provider fails to complete the CYSHCN prior authorization process. (Refer to the section “Prior Authorization”.)
• The provider must submit claims on the appropriate billing form:
  • CMS-1500,
  • UB-04, or
  • Dental Claim Form.

Third Party Coverage

• If the participant is covered by other payment sources (private insurance or MO HealthNet), claims must be filed with these payers prior to filing with CYSHCN.
• CYSHCN may be billed only after all third party sources have been exhausted.
• CYSHCN may consider the patient responsibility remaining after third party settlements.
• A copy of the Explanation of Benefits (EOB) indicating the reimbursement received from insurance, a rejection statement, and/or the MO HealthNet Remittance Advice including an explanation and/or denial codes must be submitted with the claim.
• The provider will submit any evidence regarding the filing of liens and/or litigation regarding the claim.
  • Such evidence must support the claim and contain information concerning future potential recoveries.

Submission Deadlines

• CYSHCN must receive provider claims within 90 calendar days of the date of service or within 90 calendar days of the Explanation of Benefits (EOB)/Remittance Advice (RA) process date but no longer than 6 months from the date of service.
  • Services delivered prior to June 30th must be submitted to CYSHCN no later than July 31st due to fiscal year limitations. CYSHCN is under no obligation to pay claims for dates of service in the prior fiscal year if these claims are submitted after July 31st.
• If a claim is denied for lack of required documentation (e.g. medical records, hearing aid invoice, EOB, etc.), a new claim form must be submitted with the required documentation within 60 calendar days of the SHCN warrant/voucher date. Medical records/documentation submitted without an accompanying claim form will not be processed.
• Requests for repayment of inappropriate refunds must be made within 60 calendar days of the SHCN warrant/voucher date.

Reimbursement

• Reimbursement of charges may be delayed if appropriate documentation is not received with the claim.
• CYSHCN reimbursement for eligible services must be accepted as payment in full.
  • The provider cannot request payment for eligible services from CYSHCN participants or their families.
• Repair or replacement of supplies/equipment due to any reason other than normal wear and tear or physical growth of the participant will not be considered for reimbursement. Providers shall report suspected abuse of supplies/equipment to the Service Coordinator.
• CYSHCN retains the right to deny payment when a participant becomes ineligible for coverage.
• Reimbursement is calculated based on the provider's Usual and Customary Rate (UCR) for the billed service/product.
• Claims are processed in the order they are received by SHCN, not by the date of service.

Corrected Claims

When inaccurate information has been submitted on a previous claim form, the provider must submit a new claim and indicate “corrected claim” at the top of the new claim.

Overpayments/Refunds

• If a provider submits a claim that results in an overpayment or receives payment from another third-party source, after a claim has been reimbursed by CYSHCN, it is the responsibility of the provider to notify SHCN. The provider shall submit a refund to SHCN immediately and include:
  • Participant name,
  • Participant DCN,
  • EOB/RA when applicable, and
  • Explanation for the refund.
• Requests for repayment of inappropriate refunds must be made within 60 calendar days of the SHCN warrant/voucher date.